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General NPI Number Information
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NPI Number | 1598827826
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Entity Type | Organization
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Legal Business Name | MARK J KELLY MD, INC
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Dates
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Enumeration Date | 12/14/2006
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Last Update Date | 09/26/2008
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Provider Practice Location Address
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Address Line | 2001 SANTA MONICA BLVD SUITE 590W
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City | SANTA MONICA
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State | CA
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Zip | 90404-2102
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Country | US
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Telephone | 310-829-0039
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Fax | 310-828-1791
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Provider Business Mailing Address
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Address Line | 2001 SANTA MONICA BLVD SUITE 590W
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City | SANTA MONICA
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State | CA
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Zip | 90404-2102
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Country | US
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Telephone | 310-829-0039
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Fax | 310-828-1791
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Authorized Official
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Title or Position | PHYSICIAN
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Name | MARK KELLY
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Credential | MD
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Telephone | 310-829-0039
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | G55252
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License Number State | CA
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